RBCCV Brazilian Journal of Cardiovascular Surgery Revista Brasileira de Cirurgia Cardiovascular

Keywords: Risk Factors. Cardiac Surgical Procedures. Hospital Mortality.

Keywords: Blood Coagulation Factors. Cardiac Surgical Procedures. Enzymes. Heart Rupture, Post-Infarction. Myocardial Infarction.

Keywords: Nitrites. Nitric Oxide. Respiratory Function Tests. Thoracic Surgery. Cardiaca Surgical Procedures.

Keywords: Myocardial Revascularization. Aged, 80 and over. Survival Analysis.

Keywords: Risk Factors. Mediastinitis. Myocardial Revascularization.

Keywords: Heart Defects, Congenital. Adaptation, Psychological. Mothers.

Keywords: Surgical Wound Infection. Myocardial Revascularization. Postoperative Complications. Infection.

Keywords: Cardiovascular Surgical Procedures. Prognosis. Thrombocytopenia.

Keywords: Pulmonary artery, pathology. Heart transplantation. Catheterization.

Keywords: Heart Defects, Congenital. Down Syndrome. Body Weight. Body Height. Growth.

Keywords: Aged. Cardiac Surgical Procedures. Myocardial Revascularization. Heart Valves. Risk Factors.

Keywords: Heart Failure. Heart, Artificial. Heart-Assist Devices. Long-Term Care.

Keywords: Cardiomyopathy, Hypertrophic. Cardiovascular Surgical Procedures. Treatment Outcome. Long-term Effect.

Keywords: Ductus Arteriosus, Patent. Adult. Heart Defects, Congenital.

Keywords: Cardiology. Anatomy. Eponyms. Terminology.

Keywords: Aorta. Cardiovascular Abnormalities. Connective Tissue. Pathology, Clinical.

Keywords: Cardiac Surgical Procedures. Pulmonary Atelectasis. Positive-Pressure Respiration. Physical Therapy (Specialty). Postoperative Care.

Keywords: Extracorporeal Circulation. Vacuum. Blood Transfusion.

Keywords: Aortic Aneurysm, Thoracic. Lupus Erythematosus, Systemic. Stents.

Keywords: Endocarditis. Brachial artery. Aneurysm, infected.

Keywords: Cardiac surgical procedures. Graft rejection. Heart transplantation. Biopsy.

BACKGROUND: Myocardial infarction might result in dilated left ventricle and numerous techniques have been described to restore the original left ventricle shape and identify tools for late survival assessment. The aim of this study is to compare our experience with a modified Dor procedure using a rigid prosthesis to the septal anterior ventricular exclusion procedure (SAVE) for left ventricle restoration. The EuroScore index for prediction of late follow up survival was evaluated.
METHODS: We evaluated 80 patients who underwent left ventricle restoration between 1999 to 2007 and eight patients were excluded with incomplete data. A modified Dor procedure with rigid prosthesis (MD group) was performed on 53 patients and 19 underwent the septal anterior ventricular exclusion procedure (SAVE group). The patients were classified according their left ventricle shape as type I, II or III. Kaplan-Meier and Cox proportional hazard ratio regressions analysis were performed to assess survival after both techniques and expected surgical mortality using EuroScore index ranking after 12 years of follow up.
RESULTS: The operative mortality was comparable in both groups ranked by EuroScore index. The groups were comparable for all clinical data, except the MD group had more patients using intra-aortic balloon pumps before surgery, (5.7% vs. 0; P<0.01). Kaplan Meier analysis by left ventricle shape showed comparable survival for all patients, with slightly higher survival for type I. Kaplan Meier analysis of all death showed equivalent survival curves for both techniques after 12 years of follow up (71.5 ± 12.3 vs. 46.6 ±20.5 years; P=0.08). Kaplan Meier analysis of EuroScore index for all patients showed a difference between the three ranked categories, i.e., 0 to 10%, 11 to 49% and higher than 50% expected surgical mortality after 12 years of follow up (70.9 ± 16.2 vs. 67.5 ± 12.7 vs. 53.0 ± 15.5; P=0.003).
CONCLUSION: The MD procedure showed consistent ejection fraction improvements after long term follow up. Survival was comparable for all ventricular types and for the MD and SAVE procedures. The EuroScore index is a useful index for late survival assessment of ventricular restoration techniques.

Keywords: Ventricular Dysfunction, Left. Heart aneurysms, surgery. Myocardial infarction. Angina, Unstable. Heart Ventricles surgery.

BACKGROUND: Osteopontin (OPN) has been verified to be closely associated with oncogenesis and remodeling processes. But this cytokine was rarely assessed in the presence of aortopathies, especially acute aortic dissection. The aim of the present study was to evaluate the expressions of OPN by way of molecular biological approaches so as to offer a better understanding of the possible mechanisms of the aortopathies.
METHODS: Consecutive patients with type A acute aortic dissection (20 patients), aortic aneurysm (nine patients) or coronary artery disease (21 patients) referred to this hospital for surgical operations were enrolled into this study. Blood samples of the surgical patients after systematic heparinization, and control fast morning blood samples drawn from 21 young healthy volunteers who had no evidence of any healthy problems were investigated for enzyme linked immunosorbent assay (ELISA). The surgical specimens of the aortic tissues collected from the surgical patients during the operations were obtained for quantitative realtime reverse transcription polymerase chain reaction (RT-PCR) for OPN mRNA, western blot assay for OPN protein, and for immunohistochemical staining of OPN. Ascending aortic tissues from the autopsies of the healthy individuals dying of accident were obtained as controls of immunohistochemistry.
RESULTS: By quantitative RT-PCR, the expressions of OPN mRNA were all upregulated in all three surgical groups. The quantitative results did not reveal any intergroup differences. Western blot assay revealed that OPN was positive with similar intensities of expressions in all three surgical groups. Quantitative western blot analyses of OPN expressions did not show any significance between groups. The OPN expressions by ELISA in the aortic tissue were 3.09311 ± 1.65737, 3.40414 ± 1.15095, and 1.68243 ± 0.31119 pg/mg protein in the aortic dissection, aortic aneurysm, and coronary artery disease groups, respectively. The OPN level of the patients with coronary artery disease was much lower than those with aortic dissection (P = 0.033) or with aortic aneurysm (P = 0.019). By unparametric tests, there were significant differences in the aortic OPN contents among aortic dissection, aortic aneurysm and coronary artery disease groups (P < 0.01). A significant direct correlation was present between plasma OPN concentration and the time interval from the onset to surgery of aortic dissection (Y = 0.1420X + 2.4838, r² = 0.5623, r = 0.750, P = 0.032). By immunohistochemistry, OPN was expressed in the aortic cells: in the intima, it was weaker in all three surgical groups in comparison with the healthy control; in the media, it was weak in the aortic dissection, intense positive in aortic aneurysm, focal positive in the coronary artery disease, but evenly positive in the healthy control groups; and in the adventitia, it was positive in the aortic dissection, coronary artery disease and healthy control groups, but weak positive in the aortic aneurysm group.
CONCLUSION: These data may provide evidences that OPN may play a role in the pathogenesis of aortopathies including aortic dissection, aortic aneurysm, and coronary artery disease. OPN might be of potential perspective as a clinically diagnostic tool in the evaluations of the complex remodeling process incorporating vascular injury and repair.

Keywords: Angiogenesis Modulating Agents. Aorta. Cardiac surgical procedures. Extracellular Matrix Proteins. Osteopontin.

BACKGROUND: Mediastinitis is a serious complication of median sternotomy and is associated to significant morbidity and mortality. Diabetes is a feared risk factor for mediastinitis and viewed with caution by cardiovascular surgeons.
OBJECTIVE: To identify risk factors for mediastinitis in diabetics undergoing CABG surgery with use of unilateral ITA in the Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco - PROCAPE.
METHODS: Retrospective study of 157 diabetics operated between May 2007 and April 2010. Nine preoperative variables, five intraoperative variables and seven postoperative variables possibly involved in the development of postoperative mediastinitis were evaluated. Univariate and multivariate logistic regression analyses were applied.
RESULTS: The incidence of mediastinitis was 7% (n=11), with a lethality rate of 36.1% (n=4). Variables associated with increased risk of mediastinitis were: use of pedicled ITA (OR 8.25, 95% CI 2.03 to 66.10, P=0.016), postoperative renal complications (OR 5.10, 95% CI 1.03 to 25.62, P=0.049) and re-operation (OR 7.45, 95% CI 1.24 to 42.17, P=0.023). In multivariate analysis using backward logistic regression, only one variable remained as independent risk factor: use of pedicled ITA (OR 7.64, 95% CI 1.95 to 61.6, P=0.048), in comparison to skeletonized ITA.
CONCLUSIONS: We suggest that diabetics should be considered for strategies to minimize risk of infection. In diabetics that undergo unilateral ITA, the problem seems to be related to how ITA is harvested. Diabetics should always be considered for use of skeletonized ITA.

Keywords: Mediastinitis. Myocardial revascularization. Diabetes mellitus. Mammary arteries.

BACKGROUND: Although coronary artery bypass grafting (CABG) is a good alternative therapy in severe arterial disease, it may evolve with complications, especially infections.
OBJECTIVES: To determine the incidence of infection in post-CABG and its clinical predictors in a cardiology reference center in Brazil.
METHODS: Cohort study. Data were collected from all patients undergoing CABG between January/2004 and February/2006, excluding emergency surgery, absent record of glucose blood levels preoperatively and infection prior to surgery. Statistical analysis: Student's t test, chi square, logistic regression.
RESULTS: We evaluated 717 patients, 61.9 ± 11 years old, 67.1% were men, 29.6% with diabetes, of whom 137 (19.1%) developed infection (62% respiratory, 25% superficial wound, 9.5% urinary, 3.6% deep wound). Diabetes was more prevalent in those who developed infection, as well as prolonged time of indwelling central venous catheter (79.3 ± 40.5 vs. 61.0 ± 19.3 hours, P<0.001). After multivariate analysis (model adjusted for dyslipidemia, hypertension, smoking and leukocytes), both diabetes (OR 4.18 [2.60-6.74]), prolonged central venous line (OR 1.019 [1.00-1.02] and cardiac catheterism (OR 2.03 [1.14-3.60] remained predictors of infection. While diabetes is associated with a higher percentage of infections (P <0.001), preoperative serum glucose was not associated with increased risk of infection.
CONCLUSIONS: Diabetes and permanence of central venous catheters were associated with development of infection in post-CABG. The preoperative blood glucose was not a predictor of risk of infection. It is probably necessary to study with greater detail glycemic control trans- and post-operatively.

Keywords: Diabetes mellitus. Myocardial revascularization. Infection. Risk.

BACKGROUND: Since most complications related to the operation of prosthetic heart valves is due to disturbances of flow, its hydrodynamic characterization is a useful aid in the design of new prostheses. Simulations of pulsatile flow in cardiac prostheses began nearly 40 years ago, through the development of different mock human circulatory systems, improving the clinical results interpretation. A new design of a pulse duplicator system was developed at Polytechnic School of USP to study prosthetic heart valves.
OBJECTIVE: To present the conception of a new mock circulatory system for hydrodynamic simulations of cardiac prosthetic valves and the assembly plan of an experiment whose focus is the test of mitral prosthesis.
METHODS: Its conception is based on the state-of-art's review of these studies and the experience got with the previous mock circulatory systems, particularly the one used in the Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brazil.
RESULTS: In this design, an electric servomotor controlled by computer emits, through a hydraulic piston, a pulse to the left ventricular chamber model, where the heart valves are accomodated. To characterize, in the future, the dynamic operation of mitral prosthetic valves, an experimental setup was mounted to provide measurements of volumetric flow, instantaneous pressure and velocity fields on these valves. Optical access is conveniently provided on the design, making possible the use, in the future, of a LDA system.
CONCLUSIONS: In order to improve the analysis of hydrodynamic shear stress and prediction of haemolysis, the experimental results may be used to regulate a numerical model using 'Computational Fluid Dynamics' (CFD).

Keywords: Flow mechanics. Heart valve prosthesis. Mitral valve. Hemodynamics.

INTRODUCTION: Roller pumps play an important role in extracorporeal circulation. However, occlusion of the rollers should be adequately performed and this can be adjusted mainly by two methods: static and dynamic.
OBJECTIVE: To investigate how the Brazilian perfusionists adjust arterial roller pumps in their services and evaluate the application of a Device to Assist Calibration (DAC) that facilitates roller adjustment by the dynamic calibration method.
METHODS: We installed a roller pump with accessories to perform adjustment by drop rate (static calibration) and dynamic calibration methods during the XXVIII Brazilian Congress of Extracorporeal Circulation. Perfusionists were asked to adjust the roller pump according to the procedure they usually do in their service. After each adjustment pressure was measured by dynamic calibration method with DAC. The research was approved by the Research Ethics Committee of UNICAMP, Nº 1144/2010.
RESULTS: There were 56 perfusionists in this study. Pressure average of 56 measurements of dynamic calibration was 434 ± 214 mmHg; 76% of measurements were within the recommended range for the use of the dynamic calibration method (between 150 and 500 mmHg).
CONCLUSION: Brazilian perfusionists tend to adjust roller pumps with less occlusive settings. The amplitudes of the dynamic calibration pressure tend to be smaller for more experienced perfusionists because their skills increase with time. The device can be used by the perfusionist to adjust roller pumps with greater accuracy and mainly repeatability in few minutes.

Keywords: Extracorporeal circulation. Pumps. Calibration.

OBJECTIVE: To compare mechanical ventilation weaning based on a protocol using the spontaneous breathing trial against mechanical ventilation weaning without a standardized protocol in heart patients.
METHODS: Prospective, open, randomized study. In 2006, 36 patients undergoing mechanical ventilation for over 24 hours were randomized into two groups: control group - eighteen patients whose mechanical ventilation weaning was performed according to the different procedures adopted by the multidisciplinary team; and experimental group - eighteen patients weaned according to previously established protocol.
RESULTS: Control group patients started the weaning process sooner than experimental group patients (74.7 ± 14.7 hours vs. 185.7 ± 22.9 hours, P=0.0004). However, after the experimental group patients were ready for weaning, the extubation was carried out more rapidly than in the control group (149.1 ± 3.6 min vs. 4179.1 ± 927.8 min, P < 0.0001) with significantly lower reintubation rates (16.7% vs. 66.7%, P = 0.005).
CONCLUSION: The use of a specific protocol based on the spontaneous breathing trial for mechanical ventilation weaning in heart patients had better outcomes than weaning carried out without a standardized protocol, with shorter weaning times and lower reintubation rates.

Keywords: Cardiology. Intensive care units. Ventilator Weaning. Respiration, Artificial.

OBJECTIVES: To analyze the impact of blood transfusion on the incidence of clinical outcomes postoperatively (PO) from cardiac surgery.
METHODS: Retrospective cohort study. We analyzed 4028 patients undergoing coronary artery bypass grafting (CABG), valve (TV), or both, in Brazilian tertiary university hospital between 1996 and 2009. We compared the postoperative complications between patients with blood transfusion (n = 916) and non-blood transfusion (n = 3112). Univariate analysis was performed using the Student t test, and multivariate logistic regression bivariate (stepwise forward). Were considered significant variables with P <0.05.
RESULTS: Patients who received blood transfusions had more infectious episodes as mediastinitis (4.9% vs. 2.2%, P <0.001), respiratory infection (27.8% vs 17.1%, P <0.001) and sepsis (6.2% vs. 2.5%, P <0.001). There were more episodes of atrial fibrillation (AF) (27% vs. 20.4%, P <0.001), acute renal failure (ARF) (14.5% vs 7.3%, P <0.001) and stroke (4.8% vs. 2.6%, P = 0.001). The length of PO hospital stay was higher in transfused (13 ± 12.07 days vs. 9.72 ± 7.66 days, P <0.001). However, mortality didn't differ between groups (10.9% vs. 9.1%, P = 0.112). The transfusion was shown to be a risk factor for: respiratory infection (OR: 1.91, 95% CI 1.59-2.29, P <0.001), AF (OR: 1.35, 95% CI 1.13-1.61, P = 0.01), sepsis (OR: 2.08, 95% CI 1.4-3.07, P <0.001), mediastinitis (OR: 2.14, 95% CI: 1.43-3.21, P <0.001), stroke (OR: 1.63, 95% CI 1.1-2.41, P = 0.014) and ARF (OR 1.8, 95% CI: 1.39-2.33, P <0.001).
CONCLUSION: The blood transfusion is associated with increased risk of infectious events, episodes of AF, ARF and stroke, as well as the increased length of hospital stay but not mortality.

Keywords: Blood transfusion. Postoperative complications. Hospital mortality. Cardiac surgical procedures.

BACKGROUND: It is necessary knowing the large variability of right coronary (RCA) artery specialty for its implications in surgical procedures and clinic events. This variability is usually related to the length, branches quantity, origin and irrigated territories.
OBJECTIVE: To evaluate by direct examination the morphologic expression of RCA in Colombian people.
METHODS: RCA were measured in 221 fresh hearts by RCA ostium canalization with polyester synthetic resin that was injected in their branches.
RESULTS: The caliber of the RCA proximal segment and at the level of the acute angle of the heart was 3.42 ± 0.66 mm and 2.9 ± 0.50 mm, respectively. It ended between crux cordis and the left margin in 75.6% of specimens. Posterior interventricular artery (PIA) reached the inferior third, or the apex, or the anterior interventricular sulcus in 149 (67.4%) cases. Sinoatrial node artery (SNA) originated in the right coronary in 134 (60.6%) cases, 77 (34.9%) from circumflex artery (CxA) and from both in 10 (4.5%). Posterior right diagonal artery (PRDA) was noted in 38 (17.2%) hearts, but only 6% of the sample with long PIA, concomitantly presented the PRDA (P = 0.001). In right dominance SNA were originated from RCA in 54.7% and form CxA in 46.3% (P = 0.06).
CONCLUSIONS: Caliber of the RCA and its branches is lesser than the majority of previous studies, while the PRDA frequency is slightly higher than the reported in literature. Clinical and pathological scenarios by these variations should be taken into account: hemodynamic procedures, cardiac surgery and arrhythmias from coronary occlusive disease.

Keywords: Coronary vessels. Coronary circulation. Atrioventricular Node. Sinoatrial node.

OBJECTIVE: To observe the quality of life of patients with implantable cardioversor defibrillator (ICD).
METHODS: Descriptive research with quantitative approach by means of an interview and the analysis of the Questionnaire SF-36 in a cardiovascular outpatient service. Fifty patients users of this device participated in this study during their medical follow-up in the period from January to December.
RESULTS: Out of the subjects, 19 (38%) were female and 31 (62%) male. The average age was 58.4 years, ranging from 21 to 75 years. Two domains regarding limitations by physical and emotional aspects below score 50 were observed The social aspects domain presented the higher score; 80,5. Most of the users reported that their health is a little better compared with a year ago.
CONCLUSION: The results showed that individuals' quality of life is impaired, with lower scores for physical and emotional aspects. There was not a correlation between quality of life and age, gender, marital status and educational level. However, they feel comfortable and safe with ICD benefits since it provides their maintenance in being alive protecting them of sudden death.

Keywords: Defibrillators, implantable. Quality of life. Death, Sudden. Arrhythmia, Sinus.

INTRODUCTION: Many strategies to improve services provided by for physiotherapy are based on patients satisfaction. Listen and observe the behavior of patients in a hospital is crucial to understanding and improvement of service and the hospital.
OBJECTIVE: This study aimed to identify the patient's perception undergoing cardiac surgery on the physiotherapy service provided to wards of hospitals for heart surgery reference in the city of Maceió, AL, Brazil, and from that information detect what actions are perceived as priorities for which are noteworthy plans for improvements in quality of care.
METHODS: Cross-sectional study, conducted in quality and quantity of reference hospitals in cardiac surgery in the city of Maceio, AL, Brazil, in the period from September to November 2008. The study included 30 users of the Sistema Único de Saúde, of which 12 (40%) female and 18 (60%) males. The average age of this sample was 49.2 ± 11.9 years and most belonged to socioeconomic class D (36.7%).
RESULTS: It was found that only 16.7% had contact with the physiotherapist before surgery. Regarding educational guidelines about postoperative period, only 2.9% patients reported having received them. However, 56.8% rated the care as good and 100% of patients reported believing that physiotherapy could improve their health status.
CONCLUSION: We suggest the implementation of preoperative physical therapy protocols with preventive measures and educational as well as new researchs that may characterize the population of users of health plans/private.

Keywords: Patient Satisfaction. Physical Therapy Department, Hospital. Cardiac Surgical Procedures. Physical Therapy (Specialty).

BACKGROUND: Endovascular stent-graft repair of aortic dissections is a relatively new procedure, and although apparently less invasive, the efficacy and safety of this technique have not been fully established.
OBJECTIVE: To evaluate mortality in patients with complicated Stanford type B aortic dissections submitted to endovascular treatment.
METHODS: Clinical, anatomical, imaging and autopsy data of 23 patients with complicated type B aortic dissections were reviewed from November 2004 to October 2007. The main indications for transluminal thoracic stent-grafting included: persistent pain in spite of medical therapy, signs of distal limb ischemia, signs of aortic rupture, progression of aneurismal dilation of the descending aorta during follow-up (defined as a diameter > 50 mm) and the diameter of descending thoracic aorta of 40mm or larger at the onset of aortic dissection. Data were analyzed statistically; all p-values were two-tailed and differences < 0.05 were considered to indicate statistical significance. Continuous variables were expressed as mean (± SD), and medians were compared by the Student's t test. Differences in categorical variables between the groups were analyzed by the Chi-square or Fisher's exact test.
RESULTS: The procedure presented primary technical success in 82.6% of patients. Four patients (17.4%) had an incomplete proximal entry seal. Three patients (13%) died within 30 days of the procedure and eight patients (34.8%) died after 30 days.
CONCLUSION: Endovascular correction of complicated Stanford type B aortic dissections is a feasible and effective treatment option.

Keywords: Stents. Mortality. Aortic diseases, surgery. Aneurysm, dissecting.

OBJECTIVE: Although the overall complication rate has been decreased significantly in recent years, stroke is a severe complication after coronary bypass operations. The purpose of this study is to evaluate the influence of carotid artery disease on the results of patients under CABG operation.
METHODS: In a retrospective cohort study, 1,978 patients under CABG operation were studied in Shariati Hospital between April 2002 and March 2006. The patients who had only valve replacement or non-CABG procedure were excluded from this study. As part of preoperative evaluation, carotid duplex ultrasonography scans were performed. In order to estimate the degree of carotid arteries stenosis, ultrasound imaging measurement and velocity criteria were considered. The patients were classified into three groups: those with no significant stenosis of the internal carotid artery (ICA) (moderate) group A, those with significant stenosis (sever) group B and those with the occluded ICA (critical) group C. Finally, all data were analyzed by SPSS software. Statistical analyses were performed using the following testes; chi-square, Fisher exact and Student's t tests.
RESULTS: The distribution of the 1,978 patients undergoing CABG operation were as follows: group A = 1,938, group B = 30, and group C = 10. The results of the evaluations show that perioperative stroke rates were 1.2% (24 patients) in group A, 0.4% (eight patients) in group B and 0.3% (six patients) in group C (P<0.0001). Furthermore, perioperative mortality rates for groups A, B and C were 0.1% (two patients), 0.3% (five patients) and 0.4% (seven patients), respectively (P<0.0001).
CONCLUSION: The stroke and mortality in patients undergoing CABG are increased when ICA occlusion is present.

Keywords: Carotid Artery, Internal. Dissection. Stroke. Graft Occlusion, Vascular.

This study aims to gather and present scientific evidence on the role of a physiotherapist in the pre, peri and postoperative of pediatric cardiac surgery. This professional is able to prevent, minimize or reverse possible respiratory dysfunction and motor sequelae resulting from these interventions. Studies discuss the involvement of respiratory system, specifically the clearance of bronchial secretions and ventilatory adequacy, as a result of surgical procedure. Scientific evidences suggest the effectiveness of physiotherapy in reducing indices of: pneumonia, atelectasis, hospitalization, sequelae deleterious and length of bed restriction, beyond clinical improvement. These data confirm positive contribution of physiotherapeutic intervention in these surgeries.

Keywords: Physical therapy modalities. Cardiac surgical procedures. Heart defects, congenital.

It is well-known that hypertension is a very common disease, and severe cerebrovascular accidents might occur if the blood pressure is not properly controlled. However, conditions associated with uncontrolled hypertension may be overlooked, and may become critical and eventually require a surgical intervention on an urgent basis. Coronary artery disease, acute aortic syndrome, congenital and valvular heart disease, and arrhythmias are under this topic of discussion. Of them, coronary artery disease including myocardial infarction and especially postinfarction myocardial rupture, and aortic dissection are major critical situations that physicians may encounter in clinical practice. The role that hypertension plays in these conditions can be complex, including hemodynamic, electrophysiological and biomolecular factors, where the latter may prevail in the current era. Coronary artery disease may be associated with a reduced nitric oxide synthesis. Transforming growth factor and matrix metalloproteinases have been observed in relation to aortic syndrome. Wnt, p38 and JNK signaling pathway may be involved in the development of ventricular hypertrophy responsible for cardiac arrythmias. Various gene phynotypes may present in different congenital heart defects. This article is to present these conditions, and to further discuss the possible etiologies and the potential treatment strategies so as to highlight the relevance at a prognostic level.

Keywords: Cardiac surgical procedures. Heart Diseases. Hypertension.

OBJECTIVE: In an effort to make available homografts preserved in a simpler and less costly way, we evaluated the polyethyleneglycol, L-Hydro (LH) method, that consists in the controlled extraction of antigenic substances and the incorporation of anti-inflammatory and anti-thrombotic agent.
METHODS: We substituted the pulmonary trunk in ten ovines, seven received LH treated pulmonary homografts and three, fresh pulmonary homografts, orthotopically implanted and followed-up for 320 days. Ovines where evaluated by means of laboratory tests, echocardiographic exams. At the 320 days, were euthanized, hemodynamic, radiology, macroscopic, optic/electronic microscopic, scanning/transmission evaluations were performed. Results were analyzed by Student t test of independent samples for continuous data, by variance analysis of repeated measures, and by Fisher exact test for categorical data.
RESULTS: We couldn't establish relevant differences in clinical evolution and laboratory tests between groups. Echocardiogram revealed difference in pulmonary medium gradient, which was significant 10 months follow-up, higher in the control group. Radiologic and macroscopic evaluations didn't established differences. In the optic/electronic microscopic evaluation, liner and interstitial cells were equally found in both groups. The cell liner percent calculated in both groups was similar. Cellularity nodules were observed only infresh homograft group.
CONCLUSIONS: These data indicate that both groups presented similar clinical/hemodynamic performances. The LH group's echocardiogram presented a better performance. It also presented histological evidences of interstitial and endothelial cell repopulation. In the macro/optic and electronic microscopic analysis, group L-H presented macroscopy/histological structure and ultra-structural similar to the fresh group, with the exception of nodules with higher interstitial cellularity, present only in the fresh homograft group.

Keywords: Transplantation, homologous. Heart valves. Sheep.

An emergency operation for access related acute critical limb ischemia with signs of infection is described. Inguinal femoral reconstruction was performed with a bifurcated graft constructed from the ipsilateral saphenous vein.

Keywords: Arteriosclerosis. Angiography.

The blood hypercoagulability in pregnancy increases significantly the incidence of thrombosis of mechanical valves. Acquired supravalvular aortic stenosis is extremely rare. We report the case of an immediate postpartum patient with aortic mechanical prostheses and acquired supravalvular aortic stenosis who underwent emergency heart surgery, with severe hemodynamic instability, using adapted surgical technique for correction of supravalvular stenosis with satisfactory clinical and echocardiography results.

Keywords: Aortic Stenosis, Supravalvular. Heart valve prosthesis. Thromboembolism. Pregnancy Complications, Cardiovascular.

Penetrating cardiac trauma carries high mortality rates. It has been commonly associated with stabbing, but increasing urban violence has led to growing numbers of gunshot heart wounds. The latter have higher mortality rates among penetrating cardiac injuries and may affect multiple heart chambers, with mortality rates even higher. We report a patient, victim of an attempted armed robbery, who had a transfixing gunshot wound to the heart, successfully operated at our institution.

Keywords: Heart injuries. Wounds, gunshot. Heart ventricles.

Keywords: Bioprosthesis. Heart Valve Prosthesis Implantation. Aortic Valve. Heart Valve Prosthesis.

Keywords: Aortic valve. Cardiopulmonary bypass. Heart catheterization.

Keywords: Myocardial Revascularization. Hospital Mortality. Renal Insufficiency, Chronic. Risk Factors. Creatinine.

Keywords: Heart Failure. Muscle Strength. Respiratory Muscles. Cardiac Surgical Procedures. Postoperative Complications.

Keywords: Atrioventricular block. Pacemaker, artificial. Cardiovascular surgical procedures. Heart valves. Postoperative complications.

Keywords: Angiotensin-converting enzyme inhibitors. Myocardial revascularization. Coronary disease. Coronary artery bypass.

Keywords: Pulmonary Valve Insufficiency. Pulmonary Surgical Procedures. Pulmonary Valve Stenosis.

Keywords: Aorta. Aorta, Thoracic. Smad Proteins. Transforming Growth Factor beta1.

Keywords: Intensive care units. Cardiovascular abnormalities. Receptors, vasopressin.

Keywords: Risk factors. Mediastinitis. Coronary artery bypass. Myocardial revascularization.

Keywords: Rheumatic Heart Disease. Mitral Valve Stenosis. Cardiovascular Surgical Procedures.

Keywords: Pericardium. Bioprosthesis. Tissue engineering. Transplantation, heterologous.

Keywords: Adiponectin. Coronary restenosis. Angioplasty, transluminal, percutaneous coronary.

Keywords: Primary Prevention. Endocarditis. Knowledge.

Keywords: Myocardial bridging. Coronary circulation. Endothelium.

Keywords: Atrial Fibrillation. Ablation Techniques. Treatment Outcome.

Keywords: Ischemic preconditioning. Myocardium. Myocardial ischemia. Myocardial infarction.

Keywords: Pulmonary embolism. Hypertension, pulmonary. Capnography. Models, animal. Swine.

Keywords: Myocardial infarction. Isoproterenol. Rats, Wistar.

Keywords: Physical Therapy (Specialty). Myocardial Revascularization. Preoperative Care. Postoperative Care.

Keywords: Stents. Heart Transplantation. Myocardial Ischemia.

Keywords: Hemostatics. Sternum. Cardiac surgical procedures. Postoperative complications. Surgical wound infection.

Keywords: Aorta. Endovascular procedures. Coronary artery bypass. Stents.

Keywords: Tissue Engineering. Extracellular Matrix. Biotechnology. Morphology.

Keywords: Myxoma. Heart neoplasms. Heart atria.

Keywords: Saphenous vein. Lymphedema. Coronary artery disease.

Keywords: Mediastinal cyst. Pericardium/ pathology. Cardiac surgical procedures.

Keywords: Bone wires. Chest pain. Foreign-body migration.

Keywords: Heart neoplasms. Cardiac Surgical Procedures. Heart diseases.

OBJECTIVE: The authors sought to assess biochemical, hormonal and cellular repercussions from use of cardiopulmonary bypass (CPB) in coronary artery bypass graft (CABG) surgery.
METHODS: Eighteen patients underwent on-pump CABG surgery. Mean time of CPB was 80.3 minutes. Hormonal, biochemical and cellular measurements were taken in some time points - preoperatively, immediately after coming off CPB, 24 and 48 hours postoperatively. Friedman and Wilcoxon tests were applied based on significance level of 5%.
RESULTS: There was activation and significant elevation of total leukocytes and neutrophils count over CPB, remaining this way up to 48 hours postoperatively. Total platelets count, in turn, was marked by relevant reduction immediately after coming off CPB as well as in two postoperative time points. Serum levels of total proteins and albumin, immediately after coming off CPB and also in two postoperative time points, were significantly decreased comparing with preoperative status. There was remarkable reduction of total T3, free T3 and total T4 particularly up to first 24 hours postoperatively.
CONCLUSION: In on-pump CABG surgery, inflammatory effects encompass activation of total leukocytes, neutrophils and platelets, reduction of serum level of total proteins and albumin and decreased thyroid hormones levels, especially within first postoperative 24 hours.

Keywords: Extracorporeal circulation. Myocardial revascularization. Coronary disease.

OBJECTIVE: Evaluate if the findings of multislice computed tomography (MSCT) are associated with clinical and laboratory tests routinely used in the late follow-up of children undergoing surgical treatment of total anomalous pulmonary venous connection (TAPVC).
METHODS: From January 2002 to December 2007, 12 patients operated due to CATVP were evaluated with history, physical examination, chest X-ray, electrocardiogram, echocardiography and MSCT. Specific changes observed in each one of these tests were identified and compared with MSCT qualitative findings.
RESULTS: Eleven patients were in functional class I (NYHA), three had nonspecific murmurs, and three were below the 15^th percentile of weight and height. Two had pulmonary field abnormalities and three had a slight increase of the cardiac area in the X-ray examination. In the electrocardiogram, one patient had right ventricular overload and one had junctional rhythm. All echocardiograms were within the normal range, except for one patient with stenosis between the superior vena cava and right atrium. MSCT was completely normal in four patients, three had compression of the pulmonary veins and four had significant caliber reduction, which correlated with the other findings. Thus, MSCT showed a sensitivity of 87.5%, specificity of 0.75%, positive predictive value of 87.5%, negative predictive value of 75% and accuracy of 83.3% to demonstrate anatomic changes compared to changes in the physical examination or other additional tests.
CONCLUSION: MSTC may provide valuable information and complement the diagnosis of possible anatomical and functional changes in the late follow-up of patients undergoing surgical repair of TAPVC.

Keywords: Tomography. Heart defects, congenital/surgery. Treatment outcome.

OBJECTIVES: The reconstruction of the left ventricle (LV) is effective in the treatment of ischemic cardiomyopathy with large akinetic or dyskinetic areas. However, late survival outcomes are related to the remnant left ventricular cavity size, thus eliminating intracavitary patch placement provides additional LV reduction. The aim of this study was to analyze the results with left ventricular reconstruction surgery using the concept of maximum ventricular reduction, with systematic patch abolition.
METHODS: Seventy-six consecutive patients with ischemic heart disease (age 30-78 years, mean 57.6 ± 10.1), evolving in functional class III and IV underwent surgical ventricular reconstruction with no use of intracavitary patches or Teflon strips for closing the left ventriculotomy.
RESULTS: The left ventricular end-systolic diameter decreased from 52.3 ± 5.4 in the preoperative period to 45.2 ± 6.9 mm in the postoperative period. LV ejection fraction increased from 34.2% ± 10.4% to 45.5% ± 9.4%. Associated CABG was performed in 75/76 patients with a mean of 2.4 grafts per patient. The 30-day mortality was 3/76 (3.9%). At an average follow up of 39 months, the majority of the patients (91.4%) remain in functional class I and II.
CONCLUSION: The concept of maximizing LV reduction with systematic patchless reconstruction is feasible, safe and effective, the early and late outcomes comparing favorably to previous series reported in the medical literature. Additionally, the concept meets the contemporary pathophysiologic basis of heart failure.

Keywords: Heart Failure. Myocardial Ischemia. Heart Aneurysm. Coronary Artery Bypass. Coronary Disease.

OBJECTIVES: Finding predictors of blood transfusion may facilitate the most efficient approach for the use of blood bank services in coronary artery bypass grafting procedures. The aim of this retrospective study is to identify preoperative and intraoperative patient characteristics predicting the need for blood transfusion during or after CABG in our local cardiac surgical service.
METHODS: 435 patients undergoing isolated first-time CABG were reviewed for their preoperative and intraoperative variables and analyzed postoperative data. Patients were 255 males and 180 females, with mean age 62.01 ± 10.13 years. Regression logistic analysis was used for identifying the strongest perioperative predictors of blood transfusion.
RESULTS: Blood transfusion was used in 263 patients (60.5%). The mean number of transfused blood products units per patient was 2.27 ± 3.07 (0-23) units. The total number of transfused units of blood products was 983. Univariate analysis identified age >65 years, weight <70 Kg, body mass index <25 Kg/m2, hemoglobin <13mg/dL, hematocrit < 40% and ejection fraction <50%, use of cardiopulmonary bypass (CPB), not using an internal thoracic artery as a bypass, and multiple bypasses as significant predictors. The strongest predictors using multivariate analysis were hematocrit < 40% (OR 2.58; CI 1.62-4.15; P<0.001), CPB use (OR 2.00; CI 1.27-3.17; P=0.003) and multiple bypasses (OR 2.31; CI 1.31-4.08; P=0.036).
CONCLUSIONS: The identification of these risk factors leads to better identification of patients with a grater probability of using blood, allocation blood bank resources and cost-effectiveness use of blood products.

Keywords: Blood Transfusion. Coronary Artery Bypass. Blood Cells.

INTRODUCTION AND AIMS: The long-term results after surgical repair of rheumatic mitral valve remain controversial in literature. Our aim was to determine the predictive factors which impact the long-term results after isolated rheumatic mitral valve repair and to evaluate the effect of those factors on reoperation and late mortality.
METHODS: One hundred and four patients with rheumatic valve disease who had undergone mitral valve repair with or without tricuspid valve annuloplasty were included. All patients with associated procedures were excluded. The predictive variables for reoperation were assessed with Cox regression and Kaplan Meier survival curves.
RESULTS: The mean follow-up time was 63 ± 39 months (CI 95% 36 to 74 months). The functional class III and IV was observed in 65.4% of all patients. The posterior ring annuloplasty was performed in 33 cases, comissutoromy in 21 cases, and comissurotomy with posterior ring annuloplasty in 50 patients. There was no operative mortality. The late mortality was 2.8% (three patients). The late reoperation was associated with residual mitral valve regurgitation after surgery (P<0.001), pulmonary hypertension at the pre-operative time (P<0.001), age (P<0.04) and functional class at the post-operative time (P<0.001). We observed freedom from reoperation rates at 5 and 10 years of 91.2 ± 3.4% and 71.1 ± 9.2%, respectively.
CONCLUSION: Repair of mitral valve in rheumatic valve disease is feasible with good long-term outcomes. Preoperative pulmonary hypertension, residual mitral valve regurgitation after surgery, age and functional class are predictors of late reoperation.

Keywords: Mitral valve. Mitral valve prolapse. Mitral valve insufficiency. Mitral valve stenosis.

OBJECTIVE: To analyze the effectiveness of surgical treatment of atrial fibrillation (AF) using bipolar radiofrequency ablation during mitral valve procedures of rheumatic etiology in heart surgery.
METHODS: We retrospectively reviewed medical registries of 53 patients submitted to atrial ablation with bipolar radiofrequency energy during mitral valve surgery. Thirty four (64%) patients were women and the age varied from 27 to 72 years old (average: 49.3 ± 10.7 years). Aortic and/or tricuspid procedures were also present in 36 (68%) patients. Average time of reported atrial fibrillation was 41 months (from 3 to 192 months). Type of AF was classified as: paroxysmal in 8 patients, persistent in 3, permanent in 42. Left atrium had an average size of 52.9 ± 8.5 mm. The surgeries in these series were: 47 mitral valve replacements and 6 mitral valve repairs. Eletrocardiografic follow up was 83% complete in 14 months. Data from 24h Holter were explored.
RESULTS: Seven (13%) perioperative deaths were observed and survival after 14 months was 87%. Observed heart rhythm after 1 year of surgery was sinus rhythm in 25 (66%) patients, AF in 7 (18%), flutter in 7 (13%), junctional in 1 (3%).
CONCLUSION: Bipolar radiofrequency ablation in patients submitted to mitral valve surgery of rheumatic etiology is effective in converting to sinus rhythm in 68% of patients after 14 months.

Keywords: Cardiovascular surgical procedures. Mitral valve. Rheumatic heart disease. Atrial fibrillation. Ablation techniques.

OBJECTIVE: D-dimer and C-reactive protein are of diagnostic and predictive values in patients have thrombotic tendency, such as vascular thrombosis, coronary artery disease and aortic dissection. However, the comparative study in these biomarkers between the patients with acute aortic dissection and coronary artery disease has not been sufficiently elucidated.
METHODS: Consecutive surgical patients for acute type A aortic dissection (20 patients), aortic aneurysm (nine patients) or coronary artery disease (20 patients) were selected into this study. Plasma from preoperative blood samples and supernatant of aortic homogenate of the surgical specimens were detected for D-dimer and hypersensitive C-reactive protein (hs-CRP).
RESULTS: Plasma D-dimer and hs-CRP values in type A aortic dissection or aortic aneurysm were much higher than in coronary artery disease patients or the healthy control (for D-dimer, aortic dissection: coronary artery disease, 0.4344 ± 0.2958 µg/ml vs. 0.0512 ± 0.0845 µg/ml, P < 0.0001; aortic dissection: healthy control, 0.4344 ± 0.2958 µg/ml vs. 0.1250 ± 0.1295 µg/ml, P = 0.0005; aortic aneurysm: coronary artery disease, 0.4200 ± 0.4039 µg/ml vs. 0.0512 ± 0.0845 µg/ml, P = 0.0013; and aortic aneurysm: healthy control, 0.4200 ± 0.4039 µg/ml vs. 0.1250 ± 0.1295 µg/ml, P = 0.0068; and for hs-CRP, aortic dissection: coronary artery disease, 4.400± 3.004 mg/L vs. 1.232±0.601 mg/L, P < 0.0001; aortic dissection:healthy control, 4.400 ± 3.004 mg/L vs. 0.790 ± 0.423 mg/L, P < 0.0001; aortic aneurysm: coronary artery disease, 2.314 ± 1.399 mg/L vs. 1.232 ± 0.601 mg/L, P = 0.0084; aortic aneurysm: healthy control, 2.314 ± 1.399 mg/L vs. 0.790 ± 0.423 mg/L, P = 0.0002; and coronary artery disease: healthy control, 1.232 ± 0.601 mg/L vs. 0.790 ± 0.423 mg/L, P = 0.0113). Besides, there were close correlations between plasma D-dimer and hs-CRP in overall (Y = 4.8798X + 0.8138, r² = 0.4497, r = 0.671, P < 0.001), aortic dissection (Y = 2.6298X + 1.2098, r² = 0.5762, r = 0.759, P < 0.001), and aortic aneurysm (Y = 7.1341X + 1.3006, r² = 0.4935, r = 0.7025, P = 0.048) groups rather than in the coronary artery disease or healthy control subjects. In addition, there were no significant differences between D-dimer and hs-CRP values of the aortic supernatant among groups except for undetectable D-dimer in the aortic supernatant of the coronary artery disease group.
CONCLUSIONS: The patients with acute aortic dissection and aortic aneurysm may reflect the extensive inflammatory reaction and severe coagulopathies in the patients with acute type A aortic dissection, and thoracic aortic aneurysm in comparison to the coronary patients and healthy control individuals. The detections after onset in the patients with acute chest pain may help making a differential diagnosis between the aortopathies and ischemic heart disease. The scanty significance of the tissue biomarkers may preclude their diagnostic value in clinical practice.

Keywords: Aorta, thoracic. Clinical laboratory techniques. Coronary artery disease. C-reactive protein. Fibrin fibrinogen degradation products.

INTRODUCTION: The application of two levels of ventilation by positive pressure (BiPAP^®) associated with conventional respiratory therapy (CRT) in postoperative periord of cardiac surgery may contribute to reduction of pulmonary complications.
OBJECTIVES: To evaluate the safety and compliance of preventive application of BiPAP^® CRT associated with immediate postoperative myocardial revascularization.
METHODS: 26 patients undergoing coronary artery bypass grafting were randomly allocated in one of the groups. Patients of the Control Group (CG) were treated only with conventional respiratory therapy, compared to BiPAP group (BG) (in addition to conventional respiratory therapy the patients were subjected to 30 minutes of ventilation by two levels twice a day). The conventional respiratory therapy was held in both groups, twice a day. All patients were evaluated for vital capacity, airway permeability, maximal respiratory pressures, oxygen saturation, heart rate, respiratory frequency, Volume Minute, tidal volume, systolic and diastolic blood pressure. Evaluations were performed during hospitalization preoperatively, immediately after extubation, 24h and 48h after extubation.
RESULTS: In CG 61.5% of patients had some degree of atelectasias, in comparison to 54% of BG (P=0.691). The vital capacity was higher in the GB postoperatively (P<0.015). All the other ventilometric, gasometric, hemodynamic and manometric parameters were similar between groups.
CONCLUSION: Coronary artery bypass grafting leads to deterioration of respiratory function postoperatively, and the application of positive pressure ventilation (BiPAP^®) may be beneficial to restore lung function more quickly, especially vital capacity, safely, and well accepted by patients due to greater comfort with the sensation of pain during the execution of respiratory therapy.

Keywords: Cardiovascular surgical procedures. Physical therapy modalities. Postoperative care. Pulmonary ventilation.

INTRODUCTION: After cardiac surgery, patients have a limitation in respiratory muscle strength, which favors the appearing of pulmonary complications.
OBJECTIVE: To evaluate the effectiveness of transcutaneous electrical nerve stimulation (TENS) on the painful process and respiratory muscle strength in patients undergoing coronary artery bypass graft (CABG).
METHODS: The study included patients after on-pump CABG through sternotomy, general anesthesia, without being under the influence of neuromuscular blockade, with use of chest and mediastinal tubes, and extubation within 6 hours after the procedure and presenting index equal to or greater than three visual analog scale (VAS) of pain being on the first day after surgery. We recruited 20 patients divided into two groups with no predominance of sex: the control group (n = 10), who received more physiotherapy analgesic therapy, and TENS group received analgesic therapy, physiotherapy and TENS. The TENS was applied for 30 minutes, three times a day, a 3-hour period each application.
RESULTS: For the degree of pain, there was an average start and end, respectively, 7.0 / 1.0 for the TENS group and 7.0 / 8.0 for the control group. For inspiratory muscle strength, - 102.5 cmH₂O / - 141.17 cm H₂O to the TENS group and - 97.0 cmH2O / - 100.3 cm H₂O for control. The expiratory muscle strength, 63cmH₂O/125 cmH₂O for the TENS group and 55.3 cmH₂O/53, 2 cmH₂O for the control group.
CONCLUSIONS: TENS has shown significant effectiveness in reducing pain, and the increase in respiratory muscle strength at first-day after CABG surgery.

Keywords: Pain. Muscle strength. Transcutaneous electric nerve stimulation. Cardiovascular surgical procedures.

OBJECTIVES: To compare the SjO₂ (cerebral oxygenation indicator) and SvO₂ (cardiac output indicator) during pediatric cardiac surgery with cardiopulmonary bypass (CPB).
METHODS: Retrospective study. Data of SjO₂ and SvO₂ measured simultaneously at critical time periods during cardiac surgery with CPB were analyzed by the Spearman correlation test and Bland- Altman plot.
RESULTS:Regression analysis of the pooled data showed poor correlation between SjO₂ and SvO₂ (r²=0.14, P=0.03) and Bland- Altman plot had a high bias (-7.9), indicating independency of the two variables. SjO₂<50% (indicative of cerebral ischemia-hypoxia) were observed in 50% of the measurements after rewarming during hypothermic CPB.
CONCLUSIONS: SvO₂ is not a good predictor of SjO₂ during pediatric cardiac surgery with CPB, and low SjO₂ can be undetected measuring SvO₂ only.

Keywords: Extracorporeal circulation. Child. Oxygenation. Jugular veins.

INTRODUCTION: Although hypoplastic left heart syndrome (HLHS) be extensively studied, this disease still has a high mortality rate compared to other diseases treated as univentricular physiology. In this way, morphological differences between phenotypes within the spectrum of HLHS may be risk factors and their identification can assist in choosing treatment between subgroups.
OBJECTIVE: To identify the most prevalent form of coronary artery dominance in hearts with HLHS groups with mitral atresia (MA) and mitral stenosis (MS).
METHODS: Analysis of coronary anatomy according to the distribution of epicardial branches and the pattern of dominance, classified as right, left or balanced. The control group was composed of nine pieces of morphologically normal hearts, the HLHS group consisted of 9 pieces with MA and 24 pieces with MS. For statistical analysis we used the x² test.
RESULTS: There were significant differences between the two groups in relation to coronary artery dominance (x² = 9.298, P = 0.01). Left dominance was present in 75% of cases of MS, and balanced one was only observed in pieces with MS. The control group had right dominance in all cases (P <0.01).
CONCLUSIONS: Left dominance is more common in HLHS than in the control group of normal hearts and, in HLHS, the left coronary dominance is more frequent in the subgroup with MS.

Keywords: Heart/anatomy & histology. Coronary vessels. Hypoplastic left heart syndrome. Heart defects, congenital.

INTRODUCTION: Retrograde autologous priming (RAP) is a cardiopulmonary bypass (CPB) method, at low cost. Previous studies have shown that this method reduces hemodilution and blood transfusions needs through increased intra-operative hematocrit.
OBJECTIVE: To evaluate RAP method, in relation to standard CPB (crystalloid priming), in adult patients.
METHODS: Sixty-two patients were randomly allocated to two groups: 1) Group RAP (n = 27) of patients operated using the RAP and; 2) Control group of patients operated using CPB standard crystalloid method (n = 35). The RAP was performed by draining crystalloid prime from the arterial and venous lines, before CPB, into a collect recycling bag. The main parameters analyzed were: 1) CPB hemodynamic data; 2) Hematocrit and hemoglobin values; 3) The need for blood transfusions.
RESULTS: It was observed statistically significant fewer transfusions during surgery and reduced CPB hemodilution using RAP. The CPB hemodynamic values were similar, observing a tendency to use lower CPB flows in the RAP group patients.
CONCLUSION: This investigation was designed to be a small-scale pilot study to evaluate the effects of RAP, which were demonstrated concerning the CPB hemodilution and blood transfusions.

Keywords: Extracorporeal circulation. Hemodilution. Cardiac surgical procedures.

BACKGROUND AND OBJECTIVES: Mediastinitis is a serious complication of median sternotomy and is associated to significant morbidity and mortality. The aim of this study is to identify which option of harvesting internal thoracic artery (ITA), pedicled or skeletonized, is associated with lower rates of mediastinitis after coronary artery bypass grafting surgery (CABG) in elderly, in the Division of Cardiovascular Surgery of PROCAPE.
METHODS: Retrospective study of 160 elderly who underwent consecutive CABG between May 2007 and June 2011. Eleven preoperative variables, four intraoperative variables and eight postoperative variables possibly involved in the development of postoperative mediastinitis were evaluated between two groups: CABG with skeletonized ITA (n=80) and pedicled ITA (n=80). Univariate and multivariate logistic regression analyses were applied.
RESULTS: The incidence of mediastinitis was 6.8% (n=11), with a lethality rate of 54.5% (n=6). The skeletonized ITA group were more exposed than pedicled ITA group to obesity (n=12 vs. n=4; 15% vs. 5%; P=0.035) and multiple transfusions (n=25 vs. n=11; 31.2% vs. 13.7%; P=0.008). The pedicled ITA group presented a greater risk of mediastinitis after CABG than skeletonized ITA group (n=10 vs. n=1; 12.5% vs. 1.2%; Unadjusted OR 11.3; 95% CI 1.4 - 241.5; P=0.008). In multivariate analysis, this difference maintained statistically significant (Adjusted OR 5.2; 95% CI 1.5-495.8; P=0.012), being considered an independent association.
CONCLUSIONS: We suggest that elderly should be considered for strategies to minimize risk of infection. In elderly that undergo unilateral ITA, the problem seems to be related to how ITA is harvested. Elderly should always be considered for use of skeletonized ITA.

Keywords: Myocardial revascularization. Mediastinitis. Aged.

BACKGROUND: Sternal wound infection (SWI) after coronary artery bypass graft (CABG) surgery is a major complication. Identifying patients at risk of SWI is essential for the application of preventive measures.
OBJECTIVE: To identify the pre- and intra-operative risk factors, apply the STS risk score and determine the correlation between the risk score and microorganisms isolated from surgical wounds in a Brazilian hospital.
METHODS: This is a retrospective analysis of a database of all CABG surgeries performed in a single institution from 2006 to 2008. Chi-square analysis was used for categorical variables and Student's t-test was used for quantitative variables. Multivariate logistic regression model was used to identify independent risk factors for SWI. P <0.05 was considered significant.
RESULTS: The infection rate was 7.2% (143/1975). The multiple regression analysis found the following risk factors: female gender (OR 2.06; 95%CI 1.40-3.03; P<0.001), BMI>40 kg/m² (OR 6.27, 95%CI 2.53-15.48; P<0.001), diabetes (OR 2.33; 95%CI 1.56-3.49; P<0.001), number of affected coronary arteries (OR 7.78; 95%CI 1.04-57.79; P<0.001) and use of bilateral internal thoracic artery (OR 3.85; 95%CI 2.10-7.07; P<0.001). Infected patients had a mean score of 9, whereas non-infected patients had a mean score of 7 (P<0.001). There was no correlation between microorganisms, scores and risk factors.
CONCLUSION: Female gender, diabetes, BMI>40 kg/m², number of affected coronary arteries and use of bilateral internal thoracic artery were associated with a higher risk of infection. The STS risk score can be successfully used and there was no correlation between microorganisms, the score and risk factors at our institution.

Keywords: Infection. Risk factors. Mediastinitis. Myocardial revascularization.

BACKGROUND AND OBJECTIVE: We attempt to reduce the ischemic time during implantation of the donor heart in the bicaval bipulmonary orthotopic position using normothermic beating heart and thus, facilitate the transplanted heart adaptation to the recipient. This study presents a small experience about a new strategy of myocardial protection during heart transplant.
METHODS: In cardiopulmonary bypass, the aorta anastomosis was done first, allowing the coronary arteries to receive blood flow and the recovering of the beats. The rest of the anastomosis is performed on a beating heart in sinus rhythm. The pulmonary anastomosis is the last to be done. This methodology was applied in 10 subjects: eight males, age 16-69 (mean 32.7 years), SPAo 90-100 mmHg (mean 96 mmHg), SPAP 25-65 mmHg (mean 46.1 mmHg), PVR 0.9 to 5.0 Wood (mean 3.17 Wood), GTP 4-13 mmHg (mean 7.9 mmHg), and eight male donors, age 15-48 years (mean 27.7 years), weight 65-114 kg (mean 83.1 kg). Causes of brain coma: encephalic trauma in five hemorrhagic stroke in four, and brain tumor in one.
RESULTS: The ischemic time ranged from 58-90 minutes (mean 67.6 minutes) and 8 donors were in hospitals of Sao Paulo and two in distant cities. All grafts assumed the cardiac output requiring low-dose inotropic therapy and maintained these conditions in the postoperative period. There were no deaths and all were discharged. The late evolution goes from 20 days to 10 months with one death occurred after 4 months due to sepsis.
CONCLUSION: This method, besides reducing the ischemic time of the procedure, allows the donated organ to regain and maintain their beats without pre or after load during implantation entailing the physiological recovery of the graft.

Keywords: Ischemia. Heart transplantation. Cardiac surgical procedures.

Severe ischemic heart disease with refractory angina, occurs in increasing incidence. Alternative forms of treatment, in an attempt to reduce myocardial ischemia and relief of symptoms has been studied. In this context, gene therapy is an option, for the possibility of inducing angiogenesis, establish collateral circulation and reperfuse ischemic myocardium. Several clinical trials have been conducted and, except for specific cases of adverse effects, there is indication of safety, feasibility and potential effectiveness of therapy. The clinical benefit, however, is not yet well established. In this article we review the clinical trials of gene therapy for patients with ischemic heart disease. The approach includes: (1) myocardial ischemia and angiogenesis on the pathophysiological aspects involved, (2) growth factors, dealing with specific aspects and justifying the use in cardiac patients with no option for conventional therapy, (3) controlled clinical trials, where a summary of the main studies involving gene therapy for severe ischemic heart disease is presented, (4) our experience, especially on preliminary results of the first gene therapy clinical trial in Brazil and (5) future prospects.

Keywords: Gene therapy. Myocardial ischemia. Angina pectoris.

Cardiac surgical procedures change respiratory mechanics, defecting in lung dysfunction. The physical therapists play an important role in the preparation and rehabilitation of individuals who are undergoing cardiac surgery, as they have a large quantity of techniques. The objective was to evaluate the effectiveness of breathing exercises with and without the use of devices, and respiratory muscle training in preoperative period of cardiac surgery in reducing postoperative pulmonary complications. Although there are controversies as to which technique to use, studies show the effectiveness of preoperative physiotherapy in the prevention and reduction of postoperative pulmonary complications.

Keywords: Cardiac surgical procedures. Physical therapy modalities. Rehabilitation. Postoperative complications.

We were challenged by the experience of one patient reoperation for a bioprosthetic bovine pericardium degenerative stenosis, 24 years after implantation. This bioprosthesis was implanted due to tricuspid valve bacterial staphylococcal endocarditis after septic abortion.

Keywords: Endocarditis, bacterial. Tricuspid valve. Bioprosthesis. Cardiac surgical procedures.

The aim of article is to give a brief description to the surgical strategies for patients with lone atrial fibrillation without associated cardiac operations, and present the possible indications of on-pump Maze procedures through a mid-sternotomy approach.

Keywords: Arrhythmias, cardiac. Atrial fibrillation. Cardiovascular surgical procedures.

Intracardiac myxoma is predominantly located in the left atrium but their location in the right ventricle is quite unusual. We present a case in which successful excision of the tumor was done through bicameral approach.

Keywords: Myxoma. Echocardiography. Ventricular septum.

The morphology of coronary aneurysm sets a predisposing factor to thrombus formation. However, the blood stasis caused by the change in flow may not be enough to cause thromboembolic events.

Keywords: Myocardial infarction. Coronary thrombosis. Coronary aneurysm.

Papillary fibroelastomas of the heart valves are benign, slow-growing, rare tumors of the heart. This tumor represents a potential cause of systemic embolism, stroke, myocardial infarction and sudden death. Early diagnosis is very important, as surgical excision of these tumors can prevent cerebrovascular and cardiovascular complications. Diagnosis is usually made by transesophageal echocardiogram. We describe two cases of patients with papillary fibroelastomas causing cardioembolic cerebral events, which underwent successful surgical treatment. The authors present a brief review of the literature.

Keywords: Fibroma. Heart neoplasms. Aortic valve. Stroke.